Medicare Coverage for Wegovy: Millions Could Soon Get Access

A new study has found that, following the Food and Drug Administration’s (FDA) approval of Wegovy to reduce stroke and heart attack risk in those with cardiovascular disease and obesity, millions of people insured by Medicare may soon be eligible for coverage of the drug.

Blockbuster weight-loss drug Wegovy was first approved by the FDA as an anti-obesity medication and was not eligible for Medicare coverage as a result — but its newly approved use to prevent stroke and heart attack in overweight or obese adults who don’t have diabetes means millions may soon be able to receive insurance coverage for it.

That’s according to a new report from the Kaiser Family Foundation (KFF), which found that an estimated 7% of Medicare beneficiaries, or 3.6 million overall, may soon qualify for Wegovy coverage.

For those with cardiovascular disease who are overweight or obese, medicare coverage for Wegovy will be under Part D — Medicare’s drug plans offered by private insurance companies — because it is a self-injectable drug and not administered by a health care professional.

While Part D cannot cover drugs approved only to treat obesity, the Centers for Medicare & Medicaid Services (CMS) recently released a memo explaining that Medicare Part D plans can add Wegovy now that it has a medically-accepted indication that isn’t explicitly excluded from coverage.

Wegovy, a GLP-1 agonist, contains the same active ingredient as Ozempic: semaglutide. But Ozempic has always been eligible for Medicare coverage as it is branded as a treatment for type 2 diabetes.

According to KFF’s analysis of Medicare data from 2020, 13.7 million Medicare beneficiaries had been diagnosed as being overweight or obese in 2020. Of those beneficiaries, 3.6 million also had established cardiovascular disease, meaning 26% of people on Medicare with obesity or overweight may be eligible for coverage. KFF acknowledges that this number may be even higher now, in 2024.

However, among the 3.6 million beneficiaries, 1.9 million also had type 2 diabetes, so these patients may already have been eligible for Medicare coverage of GLP-1s as diabetes treatments.

And even with insurance coverage, the monthly cost of taking Wegovy could still be hefty. KFF says that based on its $1,300 monthly price tag, Wegovy could be covered as a specialty tier drug, allowing Part D plans to charge coinsurance of 25% to 33%.

While some Part D plans have announced expanded coverage for Wegovy following its new approval for use, it’s unclear when and how many plans will choose to include it. Plans also can’t change their premiums in the middle of the year to account for the high costs of this drug, so KFF’s report says it’s likely that broader expansion will happen in 2025.

While Part D cannot cover drugs approved only to treat obesity, the Centers for Medicare & Medicaid Services (CMS) recently released a memo explaining that Medicare Part D plans can add Wegovy now that it has a medically-accepted indication that isn’t explicitly excluded from coverage.